A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

The correct answer is Choice B.

Choice A rationale

Mummy restraints, also known as swaddling, involve wrapping the infant’s body in a blanket to restrict movement. While this method can be used to calm and secure infants during certain procedures, it is not appropriate for postoperative care following cleft lip and palate repair.

Mummy restraints do not prevent the infant from touching the surgical site and may cause discomfort.

Choice B rationale

Elbow restraints are the appropriate choice for an infant postoperative following cleft lip and palate repair. These restraints prevent the infant from bending their arms and touching or damaging the surgical site. Elbow restraints allow for some movement and circulation while ensuring the surgical area remains protected during the healing process. They are commonly used in pediatric postoperative care to prevent self-injury.

Choice C rationale

Jacket restraints involve securing the infant’s torso to prevent movement. While jacket restraints can be used in certain situations to ensure safety, they are not suitable for postoperative care following cleft lip and palate repair. Jacket restraints do not specifically prevent the infant from touching the surgical site and may cause unnecessary restriction and discomfort.

Choice D rationale

Wrist restraints involve securing the infant’s wrists to prevent movement. While wrist restraints can be used to prevent self-injury, they are not the best choice for postoperative care following cleft lip and palate repair. Wrist restraints may not effectively prevent the infant from reaching the surgical site and can cause discomfort and distress. .

Choice A rationale:

Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.

Choice B rationale:

Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.

Choice C rationale:

Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.

Choice D rationale:

Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.

Choice E rationale:

Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.

Choice F rationale:

Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.